| NPI | 1699774034 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: SC 674) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: SC A674) |
| 363AS0400X Physician Assistant, Surgical (Licence: SC A674) | |
| Enumeration Date | 2005-07-19 |
| Last Update Date | 2021-11-02 |